INTRODUCTION

My client B/o Tulsi Thakur Age 05 days/female was admitted in NEONATAL ICU on
25/08/2021 at 11:00 AM with the complaint of excessive salivation, difficulty in
breathing, bluish discoloration after each feed.

BIODATA OF PATIENT:-

 NAME : B/OTULSI THAKUR

 AGE / SEX : 5days / FEMALE
 FATHERS NAME : MR.PRAKASH THAKUR
 ADDRESS : SMIRITI NAGAR , BHILAI , (C.G.)
 REGISTRATION NO. : 41711189
 DATE OF ADMISSION : 25/08/2021
 WARD/BED NO. : NICU
 EDUCATION OF PARENTS :
FATHER - 11TH CLASS
MOTHER - 9TH CLASS
 OCCUPATION OF PARENTS :
FATHER - OWN SHOP
MOTHER - HOUSE WIFE
 FAMILY MONTHLY INCOME : 30,000
 NURSING ALERT : NO ALLERGIC REACTION
 WEIGHT : 2.5 KG
 LENGTH : 50 CM.
 DIAGNOSIS : TRACHEAL ESOPHAGEAL FISTULA
 SOURCE OF INFORMATION : MOTHER

CHIEF COMPLAINT WITH DURATION:-

My patient is having difficulty in breathing & discoloration of skin

HISTORY OF PRESENT ILLNESS:-

 Onset: 5day.
 Characteristics of chief complaints:
a. Duration: -
b. Location:--
 c. Severity:-Moderate.
d. Past treatment:-no past treatment
e. Current treatment:-special feeding
f. Present status of complaint:- excessive salivation, difficulty in breathing,
bluish discoloration after each feed.

HISTORY OF PAST ILLNESS:-

 OBSTETRIC HISTORY OF MOTHER:-

PRENATAL HISTORY

- Was the pregnancy planned:-YES

- Did you receive prenatal care:-Yes
- Any problem during pregnancy:-No
- Any accidents during pregnancy:-No
- Any medication during pregnancy:-No
- Any substance abuse during pregnancy:-No

NATAL HISTORY

- Place of delivery:-Hospital
- Type of delivery:-Normal delivery
- Any problem encountered during delivery:-No any problem during delivery
time.
- Any vaginal infection:-No any vaginal infection
- Child’s apgar scoring:-5/10

POST NATAL HISTORY

- Child’s birth weight :- 2.5 kg

- Child’s length: - 50c.m.
- Head circumference: - 30 c.m.
- Did the child have any problem after birth:- yes
- Has the child ever been hospitalized:- yes
- Has the child ever had any major illness:-No my patient had not any major
illness
- Has the child ever experienced any major injuries: - No my patient had not
experienced any major injuries.
 FAMILY HISTORY:-

 Type:-nuclear family
 No. of members:-4 members
 Family medical history:-My patient’s family members are not suffering from
any diseases like hypertension, cancer, diabetic mellitus etc.
 Any major diseased cause of death in family: - No major diseased cause of
death in family.
 Any member suffered with common disease:-My patient’s family members
not suffering from any common diseases.

- Family composition:-

Patient relative Age / Sex Relationship Education Occupation Health

name
Mr.Prakash Thakur 32Y/Male Father 11th class Own good
shopkeepe
r
Mrs. Tulsi Thakur 30Y/Female Mother 9th class House wife good
Akash Thakur 4Y/Male Brother pp-2 Student Healthy
Baby of Tulsi 5 Patient - - hospitalized
Thakur day/female

- Family tree:-
Father (Mr.Prakash, 32years) Mother (Mrs. Tulsi, 30 years)

KEY-

Brother (Aakash, 4yrs) → Male

Patient

→ Female

→ Patient
 SOCIO ECONOMIC STATUS:-

HOUSING:-

 Type:-Pucca House
 No. Of rooms:-2 rooms & separate kitchen
 Toilet:-yes toilet facility having (Indian).
 Electricity:- Yes
 Drinking water:-Tap water
 Sanitation:-maintained
 Health facility near home:-Yes hospital is near to their house.

ENVIRONMENTAL CONDITIONS:-

 Factory or big market near home:-yes they have big market.

 Anyone in home smoke tobacco:-yes her father takes tobacco.

CHILD’S PERSONAL DATA:

Growth and development:-
Developmental mile stone:-
S.NO FEATURES IN BOOK IN PATIENT
.
1. Physical  Weight- 2.5-3.5kg 2.5 kg
growth  Height- 48-50C.M. 50C.M.
 Head circumference- 35C.M. 30 C.M.
 Chest circumference- 27C.M.
33C.M.
 Pulse rate- 70-190 b/mt. 120b/mt.
 Respiratory rate- 30-60 60b/mt.
b/mt.
2. Gross motor  Lies in flexed position. No.
development  When prone, pelvis is No
elevated but knees are not
beneath abdomen as they
were after birth.
 Turn head to the side when No baby could not
prone. turn her head to
the side in prone
position.
3. Fine motor  Hold hands in tight fists. Yes baby hold
development fingers tightly.
 Can grasp an object placed in Yes she drops the
the hand (palmar grasp object.
reflex) but drops it
immediately.
4. Sensory  Startled by sound (moro Yes, she startled
development reflex). by sound.
 Attentive to speech of No
others.
 Indefinite stare at Yes
surroundings.
 Protective blinking in Yes, she blinks her
response to bright light. eyes in bright
light.
5. Vocalization RECEPTIVE LANGUAGE
(speech and  Responds to human voices. No, she doesn’t
language responds to
development human voices.
) EXPRESSIVE LANGUAGE
 Opens and closes mouth as Yes, when adult
adult speaks. speaks she open
her mouth
 Cry patterns developing Yes, her cry
patterns are
developing.
 Cries when hungry. Yes, she cries
when she hungry.
6. Psychosocial  Beginning development of No
development sense of trust. Negative
counterpart: mistrust.
 Complete dependence on Yes, she is
caregivers. completely
dependence on
caregivers.
7. Psychosexual  Oral stage Present
development
8. Cognitive  The repetition of reflexive Yes, she is
development actions such as sucking even repeating
 though not hungry. reflexive actions.

IMMUNIZATION HISTORY:-

Received all the vaccines as per age:-

Age Vaccines Remarks

At birth B.C.G. Done
O.P.V Done

DIETARY PATTERN:-
Breast milk is the best for a newborn because of its nutritional value, protection
from the infection against diseases and financial and social implication it has for a
poor and over populated country like India. Human milk is superior to all other
milks. So exclusive breast feeding should be given for the first 6 months and
preferably it should continue. Average of 700ml milk is secreted by an Indian
mother and it is sufficient for the baby feeding.

How much times baby takes breast feeding:-baby is having feed in every two
hourly, in one day 8-10 times.
Any problem in feeding:-no any problem in feeding
SLEEP PATTERN:-
Timing- Sleeps for 19 to 20 hrs a day, which is normal pattern in infants.

ELIMNATION:-
 Bowel per day:-3-4 times
 Urine frequency: -6-8 time/day.
 Color of urine:-Normal
PLAY HABITS:-

S.NO PLAY STIMULATION IN BOOK IN PATIENT

.
1. Visual stimulation: encourage mutual eye Present
contact
2. Auditory stimulation: talk and sing softly to Present
infant at close range.
3. Tactile stimulation: hold, touch and rock Present
infant gently.
4. Kinetic stimulation: play when infant is alert Present
and responsive.

OBSERVATION AND ASSESSMENT:-

 General condition:- looking ill

 Sensorium:-Present
 Emotional state:-Anxious
 Foul body odour:-absent
 Foul breath:-absent

PHYSICAL EXAMINATION:-

 Temperature :-100oF
 Heart rate :-136 b/mint.
 Respiration :-48b/mint.
 SpO2 :-98%
 Skin color :-Pale
 Bleeding :-absent
 Discharge :-absent
HEAD AND BODY MEASUREMENT:-
 Head circumference:-30 C.M.
 Chest circumference:-27 C.M.
HEAD:-
 Status of fontanels
 - Anterior fontanel:-open
- Posterior fontanel:-close
 Condition of scalp:-clean & silky hair
 Shape of the skull: - No caput or cephalo-hematoma is present.
SKIN:-
 Color:-Pale
 Texture :-Dry
 Cyanosis :- yes
 Generalized petechiac :-No
 Jaundice :-No
 Acrocyanosis :-No
 Edema :-absent
 Skin turgor :-Hydrated
FACE:-
 Symmetry of face :-Normal
 Flattened :-absent
 Any folds below eyes :-absent
 Palsy :-absent
EYES:-
 Symmetry :- Normal
 Eye lashes:-Normal
 Eye brow:-Normal
 Eye balls:-Normal
 Conjunctiva:-Normal
 Cornea and iris:-Normal and no irregularities present
 Pupils :-Reactive to light
 Lens :-Transparent
 Fundus :-Normal
 Eye muscle :-Normal
 Discharge :-Present
 Squint :-absent
 Vision :-Normal
NOSE:-
 Appearance :-Normal
 External nares :-Normal
  Nostrils:-No inflammation or septal deviation seen
 Profuse nasal discharge :-Present
 Depressed nasal bridge :-No
EARS:-
 External ears :-Normal
 Hearing acuity :-Normal
 Wax :-absent
 Foreign body :-No
 Shape :-Normal
 Lesion :-absent
MOUTH AND PHARYNX:-
 Lips :- Normal
 Odor of the mouth :-No foul smelling
 Teeth :-absent
 Mucus membrane :-Normal
 Gums :-Normal
 Tongue :-Normal
 Thrush :-absent
 Cracked :- absent
 Malocclusion :- absent
NECK:-
 Head range of motion:-Yes
 Neck webbed on shoulder:-No
 Extended arms on one side:-No
 Tightness of muscle on one side:-No
 Lymph node :-absent
 Range of motion :-Possible
CHEST:-
 Shape and movement with breathing :-irregular
 Bilateral air entry :-Not properly
 Respiratory pattern :-48b/mt.
 Cough and cold :-present
 Grunting sound on expiration :-absent
 Retraction on inspiration :-present
 Heart rate :-136 b/mt.
  Heart sound :-S1& S2 sound heard, No murmurs
sound heard
 Clavicle palpable on both side :- Yes
ABDOMEN:-
 Shape:-Round and protruded abdomen seen
 Congenital anomaly:-absent
 Discharge:-absent
 Any mass:-absent
 Bowel sound:-Normal
 Umbilical bleeding:-absent
 Distension :-absent
BACK:-
 Presence of any dimple in the coccygeal or sacrococcegyl:-absent
 Sinus opening:-No
 Tufts of hair:-absent
 Tenderness:-No
 Kyphosis:-absent
 Scoliosis :- absent
UPPER EXTREMITIES:-
 Proportion to the rest of the body:-Arms is of equal length when extended
 Symmetry and spontaneous movements of arms and hands:-Present
 Check the baby hold hands in fits:-No
 Finger show webbing, polydactyly or syndactyly:-absent
 Skin tags:-absent
LOWER EXTRIMITIES:-
 Symmetry :-It is of equal length when extended
 Range of motion:-Normal
FEET:-
 Presence of creases soles:-Yes
 Acrocyanosis:-Present
 Talipesequinovalgus:-No
 Bow leg:-No
 Webbing:-No
 Polydactyl:-No
  Syndactyly:-No
 Toes and nails:-Normal, no clubbing
GENITALIA:-
FEMALE:-
 Labia majora:-The skin of the labia majora is inspected for abrasions and
ulcerations.
 Labiyaminora:-Normal
 Vaginal orifice:-Normal
 Urinary meatus:-Normal
 Clitoris : Normal
 Anus:-patent
CNS:-
 Activity:-dull
 Cry :- present
REFLEXES:-
REFLEXES STIMULATION EXPECTED AGE OF REMARK
TO ELICIT RESPONSE DISAPPEARC
E
1. Blinking Exposure of Protection of eyes Dose not Present
reflexes eyes to bright by rapid eyelid disappear
light closure
2. Rooting Touching or Head turns towards 3-4 months absent
reflexes stroking the the stimulation, when awake
cheek near the mainly to find food and 7-8
corner of the months when
mouth asleep
3. Sucking Touching the Suckling movement Begins to Present
reflexes lips with the to take in food diminish at 6
nipple of the months
breast
4. Swallowing Accompanies Food, reaching the Does not Present
reflexes the sucking posterior of the disappear
reflex mouth is swallowed
5. Gagging When more Immediate return of Does not Present
reflexes food is taken undigested food disappear
into the mouth
 that can be
successfully
swallowed
6. Sneezing and Foreign Clearing of upper air Does not Present
coughing substance passages by disappear
reflexes entering the sneezing and lower
upper and lower air passage by
airways coughing
7. Palmer grasp Object placed in Grasping of object Disappear in Absent
reflexes neonate’s palm by closing fingers 6 weeks to 3
months

8. Stepping or Hold neonate in Rapid alternating Disappear Absent

dancing a vertical flexion and with 3-4
reflexes position with extension of the week
feet touching a legs as in stepping
flat and firm
surface
INVESTIGATION-

TESTS RESULT NORMAL READINGS

Hb 12.1gm/dl 12.0-15.5gm/dl
TLC 10.7cu/mm 4.5-11.0/l
APTT 31 sec 30 to 40 seconds
Neutrophils 52% 40 to 60%
Lymphocytes 26% 20-40%
Platelet 1,68000 165-145 103/µL
Blood group O positive

DIAGNOSIS: TRACHEOESOPHGEAL FISTULA tracheoesophageal fistula (TEF,TOF) is

an abnormal connection (fistula) between the oesophagus and the trachea. TEF is a
common congenital abnormality, but when occurring late in life is usually the
sequel of surgical procedures such as a laryngectomy.

DEFINITION:-
A tracheoesophageal fistula (TEF) is an abnormal connection between these two
tubes. As a result, swallowed liquids or food can be aspirated (inhaled) into your
child's lungs. Feeding into the stomach directly can also lead to reflux and
aspiration of stomach acid and food.
(According to; PARUL DUTTA)
Tracheoesophageal fistula (TEF) is a birth defect in which the trachea is connected
to the esophagus. In most cases, the esophagus is discontinuous (an esophageal
atresia), causing immediate feeding difficulties.

RISK FACTORS-
  Having the following issues can raise baby’s risk for these conditions:
 Trisomy 13, 18, or 21
 Other digestive tract problems, such as diaphragmatic hernia, duodenal
atresia, or imperforate anus
 Heart problems, such as ventricular septal defect, tetralogy of Fallot, or
patent ductus arteriosus
 Kidney and urinary tract problems, such as a horseshoe or polycystic kidney,
absent kidney, or hypospadias
 Muscular or skeletal problems
 VACTERL syndrome, which involves spinal, anal, heart, TE fistula, kidney, and
limb issues
 Up to one half of babies with TE fistula or esophageal atresia also have
another birth defect.

CAUSES:-
IN BOOK IN PATIENT
 Frothy, white bubbles in the mouth Present
 Coughing or choking when feeding Present
 Vomiting Present
 Blue color of the skin, especially Present
when the baby is feeding
 Trouble breathing Present
 Very round, full stomach Absent

TYPES/ CLASSIFICATION-
 Type A = pure esophageal atresia;
 Type B = esophageal atresia with proximal tracheoesophageal fistula;
 Type C = esophageal atresia with distal tracheoesophageal fistula;
 Type D = esophageal atresia with proximal and distal tracheoesophageal
fistula;
 Type E = H-type tracheoesophageal fistula without esophageal atresia
PATHOPHYSIOLOGY-
DIAGNOSTIC EVALUTION-
1. History taking
 Present & past medical history
 Family history
 Lifestyle
 Socioeconomic status
2. Physical examination
 Head to toe assessment
 Vital signs
 Systemic examination
3. Blood investigation
 Complete blood count
 Liver function test

4. CATHETERIZATION- The diagnosis of EA/TEF is confirmed by attempting to

pass a nasogastric tube (a tube that runs from the nose to the stomach via
the esophagus) down the throat of infants who have require excessive
suction of mucus.

MANAGEMENT:-
 PHARMACOLOGICAL MANAGEMENT-
 Propping up infant at 30o angle.
 Nasogastric tube remains in the esophagus & it is aspirated frequently
 NPO(nothing by mouth)
 Supporative therapies include meeting nutritionals requirements IV
fluids, antibiotics, respiratory support & maintaining neutral
environment.
 SURGICAL MANAGEMENT-
 Tube placement. Management plans for a delayed repair of the
esophageal atresia may include placing a 10-French Replogle double-
lumen tube through the mouth or nose well into the upper pouch to
provide continuous suction of pooled secretions from the proximal
portion of the atretic esophagus; the baby may be positioned in the 45°
sitting position; prophylactic broad-spectrum antibiotics (eg, ampicillin
and gentamicin) may be used.

 Gastrostomy. If no distal TEF is present, a gastrostomy may be created. In

such cases, the stomach is small, and laparotomy is required; when a
baby is ventilated with high pressures, the gastrostomy may offer a route
 of decreased resistance, causing the ventilation gases to flow through the
distal fistula and out the gastrostomy site.

 TEF ligation. In cases such as those above or in cases in which a distal

fistula continues to cause lung soiling, distal TEF ligation should be
considered; this ligation is performed by means of a right-side
thoracotomy, ideally via an extrapleural approach.

 Flourish Pediatric Esophageal Atresia Anastomosis. In May 2017, the US

Food and Drug Administration approved the Flourish Pediatric
Esophageal Atresia Anastomosis (Cook Medical) for management of
esophageal atresia in infants up to 1-year-old who do not have teeth and
do not have a TEF (or have had a TEF repaired); the device closes the gap
in the esophagus by using magnets to pull together the upper and lower
portions of the esophagus; it is not indicated for use in patients in whom
the distance between the esophageal segments is 4 cm or greater.
The operative repair of an oesophageal atresia and distal tracheoesophageal
fistula
 Repair of esophageal atresia. In some pediatric surgical centers,
surgeons are gaining experience in repairing esophageal atresia by means
of a minimally invasive thoracoscopic approach; this approach should be
undertaken only by those who have extensive experience in pediatric
thoracoscopic surgery.
 Chest tube care. The chest draining tube is placed in 2 cm of water only
to seal it; it is not connected to a suction device, which could encourage
an anastomotic leak.
HOME MANAGEMENT:-

1. Feeding -
 Exclusive breast feeding.
2. Thermal regulation –
 Proper wrapping of the baby.
 Maintenance of the room temperature.
 Kangaroo mother care.
3. Prevention of infection
4. Immunization.
NURSING MANAGEMENT-

Nursing Assessment

Assessment of an infant with tracheoesophageal atresia includes:

 History- A mother who is carrying a fetus with esophageal atresia may have
polyhydramnios, which occurs in approximately 33% of mothers with fetuses
with esophageal atresia and distal tracheoesophageal fistula (TEF) and in
virtually 100% of mothers with fetuses with esophageal atresia without
fistula.
 Physical exam -The acronym VACTERL (vertebral defects, anorectal
malformations, cardiovascular defects, tracheoesophageal defects, renal
anomalies, and limb deformities) refers a set of associated anomalies that
should be readily apparent upon physical examination; if any of these
anomalies are present, the presence of the others must be assessed; the
VACTERL syndrome exists when three or more of the associated anomalies
are present; this syndrome occurs in approximately 25% of all patients with
esophageal atresia.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

 Impaired gaseous exchange related to abnormal opening between

esophagus and trachea as evidenced by cyanosis.
 Impaired swallowing related to mechanical obstruction.
 Risk for injury related to surgical procedure.
 Anxiety related to difficulty swallowing, discomfort due to surgery.
 Altered family processes related to children with physical defects.
 Risk for aspiration related to difficulty in swallowing.

Nursing Care Planning and Goals-The major nursing care planning goals for
patients with Tracheoesophageal atresia are:

 Patient is free of signs of aspiration and the risk of aspiration is decreased.

 Patient swallows and digests oral, nasogastric, or gastric feeding without
aspiration.
  Patient displays ability to safety swallow, as evidenced by absence of
aspiration, no evidence of coughing or choking during eating/drinking, no
stasis of food in oral cavity after eating, ability to ingest foods/fluids.
 Patient remains free of injuries.
 Family caregivers describe own anxiety and coping patterns.
 Family caregivers identify strategies to reduce anxiety.

Nursing Interventions-Nursing interventions for a child with tracheoesophageal

atresia are:

 Ensure safe swallowing -Place suction equipment at the bedside, and suction
as needed; ensure proper nutrition by consulting with physician for enteral
feedings, preferably a PEG tube in most cases.
 Prevent aspiration -Check placement before feeding, using tube markings, x-
ray study (most accurate), pH of gastric fluid, and color of aspirate as guides;
if ordered by physician, put several drops of blue or green food coloring in
tube feeding to help indicate aspiration. In addition, test the glucose in
tracheobronchial secretions to detect aspiration of enteral feedings; elevate
the head of bed to 30 to 45 degrees while feeding the patient and for 30 to
45 minutes afterward if feeding is intermittent; and instruct in signs and
symptoms of aspiration.
 Reduce anxiety -Allow family caregivers to talk about anxious feelings and
examine anxiety-provoking situations if they are identifiable; assist them in
developing new anxiety-reducing skills (e.g., relaxation, deep breathing,
positive visualization, and reassuring self-statements); explain all activities,
procedures, and issues that involve the patient; use nonmedical terms and
calm, slow speech; do this in advance of procedures when possible, and
validate patient’s understanding.

Evaluation-Goals are met as evidenced by:

 Patient is free of signs of aspiration and the risk of aspiration is decreased.

 Patient swallowed and digests oral, nasogastric, or gastric feeding without
aspiration.
 Patient displayed ability to safety swallow, as evidenced by absence of
aspiration, no evidence of coughing or choking during eating/drinking, no
stasis of food in oral cavity after eating, ability to ingest foods/fluids.
Documentation Guidelines

Documentation in an infant with tracheoesophageal atresia include:

 Individual findings, including factors affecting, interactions, nature of social

exchanges, specifics of individual behavior.
 Intake and output.
 Signs of infection.
 Cultural and religious beliefs, and expectations.
 Plan of care.
 Teaching plan.
 Responses to interventions, teaching, and actions performed.
 Attainment or progress toward the desired outcome.…

NURSING CARE PLAN WITH THEORY APPLICATION:-

VIRGINIA HENDERSON’S DEFINITION OF NURSING:-

INTRODUCATION:-
Virginia Henderson’s was born on 30 November 1897, in Kansas city, Missouri, and
died on 17 March 1996. Henderson’s interest in nursing evolved dursing world was
war i from her desire to care for sick and wounded military personnel. She enrolled
in the army school of nursing in Washington, DC, and graduated in 1921.
CONTRIBUTIONS:-
1. In 1937, Henderson and others created a basic nursing curriculum for
nursing in which the education was “patient centered and organized around
nursing problems rather than medical diagnoses.”
2. In 1939, she revised harmer’s classic textbook of nursing and wrote the 5 th
edition, incorporating her personal definition of nursing.
3. The founding members of ICIRN.
4. In 1978, the fundamental concept of nursing was revisited by Virginia
Henderson from Yale university school of nursing (USA).

14 HUMAN NEEDS:-

 Breathe normally.
 Eat and drink adequately.
 Eliminate body wastes.
 Move and maintain desirable posture.
 Sleep and rest.
  Select suitable clothes: dress and undress.
 Maintain body temperature within normal range by adjusting clothing and
modifying environment.
 Keep the body clean and well groomed and protect the integument.
 Avoid the dangers in environment and avoid injuring others.
 Communicate with others in expressing emotions, needs fears or opinions.
 Worship according to one’s faith.
 Work in such a way that there is a sense of accomplishment.
 Play or participate in various forms of recreation.
 Learn, discover or satisfy the curiosity that leads to normal development and
health and use the available facilities.

Nursing management
Nursing Diagnosis is:
1. Ineffective breathing pattern related to inflammatory process.
2. Altered nutrition less than body requirements related to inability to ingest
food or digest food because of biological factors.
3. Sleep pattern disturbance related to internal factor of illness.
4. Hyperthermia related to illness of lower respiratory tract infection as
evidenced by raised body temperature.
5. Anxiety of parents related to threat to or change in health status, threat to
or change in environment hospitalization.
ASSESSMENT NURSING GOAL PLANNING NURSING EVALUATION RATIONALE
DIAGNOSIS INTERVENTION
Subjective data: Impaired gaseous To improve Assess the level of Assessed oxygen To assist in At the end,
My client exchange related the breathing at least 4 saturation every 4 creating an baby had an
compliant that she to abnormal breathing hourly. hourly. accurate diagnosis. oxygen
is having pain In opening between pattern & to saturation of
perineum while esophagus & increase 99% baby skin
urinating. trachea as oxygen To provide oxygen Provided oxygen To maintain the is not blue
evidenced by saturation. therapy via nasal cannula therapy via nasal saturation level. now.
Objective data: cyanosis. at 2L/ hr. cannula at 2L/ hr.
On observation I
found that client is
going through severe To provide suctioning to Provided suctioning To relieve &
the mouth & nasal to the mouth & prevent airway
pain as evidenced by
nasal. obstruction.
facial expression
To provide comfortable Provided Allows full
environment & semi comfortable expansion of the
fowler’s position environment & semi lungs to assist
fowler’s position baby with
breathing.

NPO until cause of Asked the mother of Prevent airway

distress is known. the client to keep obstruction &
the baby NPO. hypoxia.

ASSESSMENT NURSING GOAL PLANNING NURSING EVALUATION RATIONALE

 DIAGNOSIS INTERVENTION
Subjective data: Knowledge To Assess the level of Assessed the level of To determine She gained
My client’s mother deficient related increase understanding understanding. deficiency of sufficient
asked that she is to lack of the knowledge related knowledge
having less information knowledge to patient’s regarding the
knowledge about the resource. related to condition. disease
her baby,s condition. disease condition.
condition.
Assess the readiness to To address the
Assessed the
learn, misconceptions & patient’s cognition &
readiness to learn,
blocks to learning mental status
misconceptions &
blocks to learning towards new
diagnosis & to help
the patient
overcome blocks to
learning.
Develop therapeutic
Objective data: nurse-client relationship. Developed Promotes trust.
On observation I
therapeutic nurse-
found that client’s
client relationship.
mother always Encourage / allow her to
asking relevant ask or express her feelings
questions regarding & doubt. Encouraged the
the disease To increase
client.
condition. knowledge &
decrease the
anxiety.
PROGNOSIS:-
FIRST DAY:-
On the first day when I meet the B/O Tulsi she is conscious and she was
admitted in hospital with complain of-
- Excessive salivation
- Breathing difficulty.
- Tachypnea.
- Dullness.
Vital signs:-
 Temperature:- 100.00F
 Pulse :- 120 b/mt.
 Respiration :- 60 b/mt.
Treatment:-
 To assess the general condition.
 I checked vital signs of the baby.
 Observed the respiration and its pattern Respiration is 60 b/mt.
 Assessed the patient temperature (100oF).
 Administered the drug as prescribe by the physician.
 Maintained environmental temperature of 72oF and provided
lightweight clothing

SECOND DAY:-
On the second day she is conscious today also she has fever but reduce to first
day, tachypnea, dullness also having. Today done investigation.
- Blood group
- CBC
Vital signs:-
 Temperature:-99.60F.
 Pulse :- 120 b/mt.
 Respiration :- 56 b/mt.
Treatment:-
 Assessed the condition of the baby
 I checked vital signs of the baby.
 Assessed skin for pallor or cyanosis.
 Administered IV fluids as prescribed by physician.
 Monitored daily intake and output of baby.
 Provided quite environment.

THIRD DAY:-
 On the third day she is conscious and today she has undergone the
surgery.
Vital signs:-
 Temperature:-99.00F.
 Pulse :- 130 b/mt.
 Respiration :- 54 b/mt.
Treatment:-
 Observed the baby condition.
 Checked vital signs.
 Position with head elevated or seated upright with head on pillows,
position on side if more comfortable.
 Pre op care given to the patient.
 Consent is taken from the parents

FOURTH DAY:-
Client her condition is good. Post op. care is given to the patient now also
patient is in NPO.
Vital signs:-
 Temperature:-98.60F.
 Pulse :- 130 b/mt.
 Respiration :- 38 b/mt.
Treatment:-
 Assessed the baby.
 Checked vital signs of the baby.
 Avoided visitor at sleeping time.
 Antibiotics, if needed, should be given as for the prescribed period.
 Children should avoid exposure to infection.

FIFTH DAYS:-
Client condition is good, now she is allowed to take milk, iv fluids & antibiotics
are given & vitals are monitored every 4 hourly.
Vital signs:-
 Temperature:-98.60F.
 Pulse :- 126 b/mt.
 Respiration :- 38 b/mt.
 Treatment:-
 Observed the baby.
 Checked vital signs.
 Light should be off when she sleep.
 To the assess patient to maintain the personal hygiene.
 Parent should be explained and advised about the care to be provided at
home.

HEALTH EDUCATION:-
About diseases:-

About personal hygiene

 Personal hygiene-
- I advice to the parents wash the hand before and after meal and toilet.
- Take daily bath.
- Cut the nail when it grows.
- Massage the newborn baby (oil massage).
- Clean the breast before and after breast feeding.
 Diets-
- I advice my patient mother give breast feeding properly.
- I advice my patient mother before give breastfeedingclean her breast
properly.
 Medication-
- I advice my patient family members give medication with doctor advice.
- Follow 6 rights before given medication.

CONCLUSION:-
My client B/O Tulsi Thakur daughter of Mr.Prakash Thakur was came in C.M.
hospital on 27/07/21 in Smriti Nagar, Bhilai (C.G.). She was admitted in hospital
with complain of- of excessive salivation, difficulty in breathing, bluish
discoloration after each feed.
BIBLIOGRAPHY:-
1. Dorothy R. Marlow, Barbara A. Redding; “Textbook of Pediatric
Nursing”; Edition-6th; Page No. 753-754
2. Ghai O.P.; “Ghai Essential Pediatrics”; Edition- 6th (Revised
enlarged); CBS Publisher Page No. 189-200
3. Hockenberry; “Wong’s Nursing Care of Infants & children”;
Edition 7th; Mosby Publisher; Page No. 527-541.
4. ParulDutta; “TEXT BOOK OF Pediatric Nursing”; Edition 1st ;
Jaypee Publication; Page No. 36-46
5. Piyush Gupta; “Essential of Pediatric Nursing”; Edition 2nd; CBS
Publisher; Page No. 298-299
6. Susan Rowen James; Nursing Care of Children; Edition; 2nd
Saunders Publishers; Page No. 86-89
7. Terry Kyle; Essentials of Pediatric Nursing; Edition 1st; Lippincott
Publication; Page No 225
8. www.verywellfamily.com
9. en.m.wilipedia.org

C.M. NURSING INSTITUTE

 NEHRU NAGAR, BHILAI

SUBJECT; OBSTETRICS & GYNAECOLOGICAL NURSING

TOPIC ; CASE PRESENTATION ON -
TRACHEOESOPHAGEAL FISTULA

SUBMITTED TO; SUBMITTED BY;

Mrs. GEETANJALI DESHMUKH Mrs. R JHANSI

ASSISTANT PROFESSOR M.Sc. (N) 1ST YR.